Merker, David 11-15-24- Qualifying Documents }a+li l 15 '24 .'_:59Pt'1
c Y CLEF!'.
CITY OF BOYNTON BEACH
,_,;NTUN hEFiCi-+
CANDIDATE QUALIFYING CHECKLIST
Candid te's Name: hc), dA,g, ,L( ✓ Mayor _District I 0 District 3
Qualifying Information
'dency Requirements Statement
rticle I
Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates
i
(DS-DE 9). dor t^^.\� 1..)0.1.
Candidate signature oir-Block 26
Campaign Treasurer signature on Block 27
Form is completely filled out
Note: Only one primary and one secondary depository can be designated
ig,
Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates
S-DE 9).
Candidate signature on Block 26
_ Campaign Treasurer signature on Block 27
_Form is completely filled out
Note: Only one primary and one secondary depository can be designated
E!tatement of Candidate(DS-DE 84).Db*-12 Ctunyn VCF3-
Oath of Candidate (DS-DE 302NP). (Accepted at time of qualifying)
Note: the Candidate prints name as they wish it to appear on the official ballot
,Statement of Financial Interest Form 1 (CE Form 1). (Accepted at time of qualifying)
0 Form is completely filled out
Filing Fee for City Commissioner=$25.00 (Accepted at time of qualifying)
CHECK MUST BE FROM CAMPAIGN ACCOUNT(EXAMPLE: JOHN DOE CAMPAIGN
A COUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER).
Election Assessment Fee for City Commissioner=$13.69-(1% of salary-Commissioner salary=
$22,369) (Check made out to City of Boynton Beach). (Accepted at time of qualifying)
CHECK MUST BE FROM CAMPAIGN ACCOUNT(EXAMPLE: JOHN DOE CAMPAIGN
ACCOUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER).
Petition Handbook
�fwenty-five (25) signed petitions that have been certified by the Palm Beach County
Supervisor of Elections a cost of 10¢ per name. (As of 2021, Candidates are
required to submit petitions to the City Clerk who will in turn will have them certified
by the PBC Supervisor of Elections. Please submit petitions no later than November
15th to help ensure they are certified prior to the end of qualifying.)
Resign to Run
Resign
(Candidate must resign in writing from elective or appointive office no less than ten (10) days prior to
the first day of qualifying) (F.S. 99.012)
I, `v , , 64 , acknowledge receipt of printed copies of the following:
J orida Election Code
J 024/2025 Election Calendar
3 andidate & Campaign Treasurer Handbook
3 1 esignation of Poll Watchers
J ' opy of Treasurer's Report Documents
3 lection Code for the City of Boynton Beach
J ode of Ethics for Palm Beach County
go unshine Amendment and Code of Ethics for Florida
5/City Map
a 'recinct List for Boynton Beach as of 11-01-2024
J Notice of Logic & Accuracy Test for Election and Run-Off Election- TBI)
Comments
1
Candidate's Signa tu 6C Date: ,'aI2..
%'\
��j�jChecked: Reviewed: (,�, ,� Date: A'/IC/VOA/
RESIDENCY REQUIREMENTS
, candidate for
(Print Name)
2 of the City
(Mayor/Co missioner — District #)
of Boynton Beach, have received, read and
understand the residency requirements of Article I of
the Charter of the City of Boynton Beach.
avjtro
c) c\ /)\\.
(Signature of Candidate)
111 'o
(Dat )
CANDIDATE OATH
NONPARTISAN OFFICE
(Do not use this form if a Judicial or School Board Candidate)
Check box only if you are seeking to qualify as a write-in
candidate:
Write-in candidate
OFFICE USE ONLY
Candidate Oath
Name to appear on ballot:
Check box if two last names without hyphen. ❑ (Name cannot be changed after qualifying.)
Check box if name includes nickname. ❑ (For use of a nickname,you must complete the Nickname Affidavit on reverse side.)
I swear or affirm that I am a candidate for the nonpartisan office of
1".\--)fVf e) (District#)
; I am a qualified elector of PIY'n Rey' • '! County, Florida
(Circuit#) (Group or Seat#)
I am a qualified elector under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or elected; I
have qualified for no other public office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I
have resigned from any office from which I am required to resign pursuant to Section 99.012, Florida Statutes; and I will support the
Constitution of the United States and the Constitution of the State of Florida.
Statement of Outstanding Fines, Fees, or Penalties
I owe outstanding fines, fees, or penalties,that cumulatively exceed $250, for ethics or campaign finance violations (s. 99.021(1)(d), F.S.).
YES, I Do NO, I Do Not )e
If you do, you must also specify the amount owed and each entity that levied the same on the reverse side.
X ) n-51- ;-k11,•\
Signa ure of Candidate Telephone Number Er Address
dress of Legal esi ence City State ZIP Code
STATE OF FLORIDA C� —r
COUNTY OF cP�,i(n .6- ct\ Signature •f •tary Public
l Print,Type„+r, • : Commission Name of Notary Public below:
Sworn to (or affirmed)and subscribed before me by means of
online notarization ❑ OR physical presence ,'��� �yP '
this /911 day of WerYle f , 20 . 5\ 5
Personally Known ❑ OR Produced Identification El = �yGO�sti
Type of Identification Produced: (, rwQ U l e P - ce F�0'
STATEOF <1/4
•....... ��,
DS-DE 302NP (Eff. 10/2023) "',,,,,,M/SSION Rule 1S-2.0001, F.A.C.
Phonetic Spelling of Name
Phonetic spelling for the audio ballot(not required for qualifying purposes): Print the name phonetically on the line below as you
wish it to be pronounced on the audio ballot as may be used by persons with disabilities (see instructions on page 3 of this form):
MIC-—Viet,
Statement of Outstanding Fines, Fees or Penalties
Pursuant to Section 99.021(1)(d), F.S., each candidate, whether a party candidate, a candidate with no party affiliation, or a write-in
candidate, shall, at the time of subscribing to the oath or affirmation, state in writing whether he or she owes any outstanding fines,fees,
or penalties that cumulatively exceed$250 for any violations of s.8,Art. II of the State Constitution,the Code of Ethics for Public Officers
and Employees under part III of chapter 112, any local ethics ordinance governing standards of conduct and disclosure requirements,or
chapter 106.
Amount Entity
Affidavit of Nickname (Only required if using nickname for the ballot.)
My legal name is . I am over the age of eighteen (18)and the contents of this
affidavit are true and correct.
My nickname is . I am generally known by this nickname or have used it as part
of my legal name. I have not created the nickname to mislead voters. My nickname does not imply I am some other person, constitute
a political slogan or otherwise associate me with a cause or issue, or that is obscene or profane.
Signature of Candidate:
STATE OF FLORIDA
COUNTY OF
Signature of Notary Public
Print,Type,or Stamp Commissioned Name of Notary Public below:
Sworn to (or affirmed)and subscribed before me by means
of online notarization ❑ OR physical presence ❑
this day of ,20
Personally Known ❑ OR Produced Identification ❑
Type of Identification Produced:
DS-DE 302NP (Eff. 10/2023) Rule 1S-2.0001, F.A.C.